Survival rates after curative gastrectomy for advanced gastric cancer among 238 patients in whom the cancer was invading the serosa were compared with 283 patients without serosal invasion. Generalized Wilcoxon estimates for 5-year survival rate were 47.1 per cent for patients exhibiting serosal invasion and 75.9 per cent for patients without serosal invasion. The frequency of lymph node metastasis increased proportionately with the extent of serosal invasion: 18.4 per cent in cases of S0; 53.8 per cent in cases of S1; 80.0 per cent in cases of S2; and 91.4 per cent in cases of S3. The higher the aggregate total of S (serosal invasion) and n (lymph node metastasis) factors, the lower the 5-year survival rate. In addition, patients with serosal invasion had a propensity for peritoneal dissemination of cancer cells; the percentage of cases with intraperitoneal free cancer cells increased with the extent of serosal invasion. It is worth noting that when cancer infiltration proceeded to the deeper layers and was accompanied by nodal metastasis, cancerous invasion of the perinodal fatty tissue was frequently evident. Therefore, unfavourable prognosis after curative resection in gastric cancer patients with serosal invasion may be largely dependent on whether or not the cancer has invaded the peritoneal cavity and the perinodal fatty tissue.

Pouch and Roux-en-Y reconstruction is the most useful of the three procedures for improving the postoperative quality of life. In patients with pouch and interposition reconstruction, the clinical assessment was quite poor, even though it is a physiologic route.

Background. The prognostic significance of preoperative serum carcinoembryonic antigen (CEA) determination in patients with gastric cancer has been controversial. Methods. The correlation between preoperative serum CEA levels and clinicopathologic factors was evaluated in 865 patients with gastric cancer who underwent gastrectomy between 1980 and 1990. The authors also investigated whether preoperative CEA levels represented a prognostic parameter using Cox's proportional hazard model. Results. Of the 865 patients, 249 (28.8%) were positive for CEA. The positivity rate was higher in the elderly, in male patients whose tumors were located in the lower third of the stomach, and in those with Borrmann types 2 and 3. It was also significantly correlated with tumor size, depth of invasion, lymph node metastasis, peritoneal and liver metastases, and cancer stage. The higher the serum CEA level, the more advanced the cancer stage, and the rate of curative resection also decreased as CEA levels were elevated. There was a significant difference between patients with CEA levels below 10 ng/ml and those with levels exceeding 10 ng/ml with regard to tumor progression and curability. Multivariate analysis showed a strong and highly significant association between preoperative serum CEA level and survival time. The prognosis was also significantly poorer when the CEA level was above 10 ng/ml, even in patients in the same stage (Stages 1, 2, and 3). Conclusions. Preoperative serum CEA determination in patients with gastric cancer valuable for predicting tumor progression and prognosis. Further, in patients in Stages 1, 2, and 3, CEA levels exceeding 10 ng/ml are clinically significant and provide more prognostic information than that obtained by conventional staging methods. Cancer 1994; 73:2703–8.

The authors modified the operative procedures used in pouch and interposition (PI) reconstruction in an attempt to improve the surgical results after total gastrectomy, because a randomized controlled trial had revealed that the clinical assessment of PI was quite poor, even though it is a physiological route. In most of the treated patients, the gastric emptying test revealed delayed emptying, and an X-ray video film showed folding and twisting of the jejunal conduit between the pouch and duodenum, which disturbed the transmission of nutrition. Modified PI (m-PI) was performed by decreasing the length of the jejunal conduit and widening the mesenteric pedicle to preserve the blood and nerve supply. This procedure was retrospectively compared with the previously used PI reconstruction by evaluating the postprandial symptoms, food intake, body weight, serum nutritional parameters, and emptying time of the gastric substitute. The m-PI group (n = 6) showed a lower incidence of symptoms, a greater food intake, and a greater weight recovery than the PI group (n = 6). The gastric emptying test also revealed an acceptable degree of emptying. We thus conclude that the m-PI reconstruction is more useful for improving the postoperative quality of life than the previously used method of PI reconstruction.

Spiral computed tomography (SCT) is a recently introduced technique which enables scanning of one large volume with no interscan intervals. Three-dimensional reconstruction using this technique is emerging as an effective means of identifying complex anatomical relationships. Ninety-two patients with cholecystolithiasis including ten with choledocholithiasis were investigated. All underwent SCT after oral and intravenous infusion cholangiography (IVC-SCT) and 22 were also examined by endoscopic retrograde cholangiography (ERC). IVC-SCT showed significantly more anatomical detail than conventional intravenous infusion cholangiography (IVC). The junction between the cystic duct and the common bile duct could be identified before surgery in 19 of 22 patients undergoing ERC, in 18 of 22 receiving IVC-SCT and in five of 22 undergoing IVC. Significant differences were noted between IVC-SCT, ERC and conventional IVC. Three-dimensional surface reconstruction of the biliary tract is useful in the evaluation of anatomical relationships between the cystic duct and the common bile duct (clearly seen in 86 per cent of cases). Three-dimensional reconstruction using SCT scanning is useful for anatomical assessment before laparoscopic cholecystectomy.